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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444415893
Report Date: 07/27/2021
Date Signed: 07/27/2021 01:42:55 PM

Document Has Been Signed on 07/27/2021 01:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:PEREZ, MA DE LA LUZFACILITY NUMBER:
444415893
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
07/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Ma de la Luz PerezTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) Fermin Campos-Jaramillo conducted an unannounced annual one year required and increase of capacity inspection to the home today. LPA met with Ma de la Luz Perez, Licensee, and explained the nature of today's inspection to her. Days and hours of operation are Monday to Friday from 6:00 AM to 6:00 PM. The adults that reside in the home are the Licensee, and her daughter Carla. LPA observed there were 3 preschool children in care during today's inspection. Licensee's helpers Carla and her 17 years old son were present and reside in the home. Certification for CPR and First Aid Card for Licensee are current and will expire on 8/08/2022
LPA toured the indoor and outdoor areas of the home during today's inspection. LPA obtained a copy of the children's roster today and it is current. LPA reviewed 3 children's files and observed that parent's rights forms, immunization records forms, consents for emergency medical treatment forms, and Identification and emergency information forms are in each file. LPA observed that Licensee has conducted a fire drill during the last six months. Last fire drill was documented on 7/07/2021.
The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. Off limit areas inside the home are: Three bedrooms, one bathroom, and the attached garage. Off limits areas outside: The right and left side yards. The home has back yard and it is fenced, Licensee uses the back yard as playground for the children in care.
LPA observed a fully charged 3A40BC fire extinguisher last time serviced on 4/08/2021, and at least one working smoke detector.
LPA observed the home has a carbon monoxide detector. LPA observed there aren't stairs in the home. LPA observed the home does not have wall heaters, or bodies of water. The Licensee states that she does not have any weapons in the home. LPA reminded licensee that all the detergents, cleaning compounds, medications, and other similar items are stored inaccessible to children. LPA discussed Incidental Medical Services with licensee. According with the SB792, Licensee has in file proof of immunization for pertussis, measles, and influenza for herself and for her adult helper.
******************Report dated 07/27/2021 continues in page 2.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: PEREZ, MA DE LA LUZ
FACILITY NUMBER: 444415893
VISIT DATE: 07/27/2021
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Report dated 07/27/2021 continues from page 1.
A review of staff records on 07/23/2021 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA also reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.
Supervision of children was discussed with the Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensee understands her current capacity options and she understands that she cannot have more than 8 children in the home at any time and ratio must be observed. Licensee states that she does not transport children via vehicle and that she understands that children cannot be left in parked vehicles unattended at any time. Licensee uses redirection and communication with children as a form of discipline.
Department website: www.ccld.ca.gov provided to Licensee. LPA discussed the requirements of AB 633 whenever a Type A deficiency is cited. LPA also discussed "zero tolerance" related regulations with Licensee.
Licensee and her helper Carla have completed the "Mandated Reporter" training both on 4/25/21 and Licensee was advised that all adults in contact with children are required to complete the "mandated reporter" training and the training must be renewed every two years. LPA referred the Licensee to the Department website: www.mandatedreporterca.com. for additional information on the online training.
LPA advised licensee of the new regulations on Safe sleep for infant children. and provided licensee with form LIC9227. LPA referred the Licensee to the Department website: www.ccld.ca.gov for additional information.
LPA provided licensee with the Lead Poisoning Facts sheet.
There were not deficiencies cited during today's inspection. Licensee's rights form was printed and was handed to Licensee.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS
LPA conducted an exit interview with the licensee and advised her that a large FCCH license will be approved pending on the following: 1) Approval from a manager of the Licensing Department.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
LIC809 (FAS) - (06/04)
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